- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,303.14 / $1,303.14 / $1,303.14
| Facility | | $1,303.14 | $1,303.14 | $1,303.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.14 / $1,438.01 / $2,388.73
| Professional | | $1,303.14 | $1,438.01 | $2,388.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,662.57 / $8,369.40 / $14,508.52
| Facility | | $4,662.57 | $8,369.40 | $14,508.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.79 / $4,245.14 / $5,148.74
| Professional | | $2,498.79 | $4,245.14 | $5,148.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,032.88 / $4,733.55 / $11,387.19
| Facility | | $3,032.88 | $4,733.55 | $11,387.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.44 / $4,299.00 / $5,909.92
| Professional | | $2,406.44 | $4,299.00 | $5,909.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,628.26 / $4,319.67 / $8,966.29
| Facility | | $2,628.26 | $4,319.67 | $8,966.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.63 / $3,921.68 / $5,403.41
| Professional | | $2,382.63 | $3,921.68 | $5,403.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.44 / $2,318.04 / $4,070.65
| Facility | | $1,412.44 | $2,318.04 | $4,070.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.59 / $3,331.76 / $10,702.45
| Professional | | $1,701.59 | $3,331.76 | $10,702.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $2,260.00 / $5,379.86
| Facility | | $796.00 | $2,260.00 | $5,379.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.92 / $3,037.53 / $5,687.41
| Professional | | $1,650.92 | $3,037.53 | $5,687.41 |